Why Nutrition Matters in HIV Patient Care

Nutrition has been referred to as one of the great "black boxes" that remain in HIV patient management. Long overshadowed by dramatic advances in antiretroviral therapy and more medicine-oriented approaches to disease management, we frequently underappreciate the potential for dietary and nutritional interventions to significantly improve patient health and HIV treatment outcomes.

It's time to shine a brighter light on those potential benefits, and to more deeply explore what we do and don't know about the intersection between nutrition and HIV care. To that end, I spoke by phone with Jül Gerrior-Schofield, M.A., R.D., L.D.N., a senior research dietitian at the Tufts University School of Medicine. We began by discussing Ms. Gerrior-Schofield's background in the field.

Jül Gerrior-Schofield: I'm a registered dietitian. I specialize in HIV and nutrition in both a clinical and a research setting; I have done so since 1996, as a matter of fact. I've been around for a long time.

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I came over to Tufts in 1999 because Tufts historically has been and continues to be a leading nutrition school. They have the Jean Mayer Human Nutrition Research Center on Aging. It's a very large component of nutrition, in general. When we were asked to come over in 1999, there was a cohort study called Nutrition for Healthy Living. Dr. Sherwood Gorbach was the investigator and my boss Christine Wanke, another infectious disease physician, was invited to be the coinvestigator and ultimately the director of the program.

The cohort study is looking at the effect of HIV on nutritional status, and vice versa. It's for all people living with HIV. We were seeing participants every six months, and we followed them for 15 years. We've learned a lot, especially in the pre-HAART and post-HAART era.

When you look at the general audience, or at the HIV population across the country, I don't think nutrition is being discussed very often. Our data was out there, although different in the early days because the issues were different. It's still out there, but other areas of HIV care just take priority.

Some of the information I can share today is about some of the data and information that we've learned. But like I said, generally speaking, as people have gotten healthier living with HIV, nutrition has taken a back burner. It's not as pressing as it was when people were wasting, back in the early days.

Myles Helfand: Would you say that it's the rise of antiretroviral therapy that has caused a reduction in the amount of attention that we pay to nutrition?

Jül Gerrior-Schofield: I think so. Back in the early phase of the epidemic, wasting was so critical that everybody was focusing on how do we manage it? There were a lot of studies trying to combat the effects of wasting syndrome using factors like human growth hormone and Megace. Megace is a product that helps to increase appetite. People were dying of malnutrition. It was a big, huge area.

Just like in cancer, when they have this terminal illness -- which is what most people with HIV felt they had back then -- they were taking all kinds of different cocktails of supplementation: echinacea, milk thistle and all kinds of things that they were grabbing on to because there just was no way of knowing how people were going to do on the early antiretroviral meds. And the meds were so toxic, anyway.

People gained weight, but the weight that they gained was actually fat, not lean muscle. So there was a push on doing analysis of body composition in the early 2000s. That was also very critical: What is your lean body mass? When you weigh yourself on the scale, you may have gained weight, but is it functional mass? Or is it actually fat mass?

As disease management has progressed, physicians are looking at not just the virus anymore. "Let's look at the virus, look at the CD4 count" -- that was our concern, rather than looking at the whole body. There's more to it than just the virus. There's coinfection with hepatitis C; and there's diabetes; and there's cardiovascular risk; and there's primary care, which also takes an enormous amount of time. A lot of HIV providers are now doing primary care. There's just little time in clinics. Where does nutrition fit in?

Unfortunately, it takes a real backseat. But I believe, and the people I work with believe, that nutrition can become a really critical component of making people well, and reducing their risk of progression to cardiovascular disease and things like that.

Myles Helfand: Walk me through a couple of the key ways in which nutrition plays such a critical part of HIV care that it would warrant a greater level of attention from providers who may not feel they have the time. How do you make that case?

Jül Gerrior-Schofield: Here's a good example of how nutrition can actually help, rather than just say, "Oh, we know it does great things." When we look at lipodystrophy patients in our study, we look at their diets; we analyze what they're eating.

When you look at people who eat fiber -- they're getting fruits and vegetables and whole grains, particularly fruits like apples and pears, which provide pectin -- the people who eat high fiber are actually at reduced risk of developing increased obesity or trunk fat. We were able to see that in our analysis. It just makes us realize that doctors can say, "Hey, are you eating your fruits and vegetables?" That little bit of knowledge, it can really go a long way.

We also know that eating high amounts of omega-3 fatty acids, which come from salmon and sardines and plant-based vegetables (flaxseed, walnuts) -- and you can take actual capsules [as a supplement] -- can lower triglyceride levels, which are a very strong independent risk factor for an increase in cardiovascular risk. So a couple of simple nutrition tips can really make a big difference.

At least a fish oil capsule is not going to cost as much as something like TriCor [fenofibrate], which is a medication that's going to reduce your lipids. Getting them off of some medications would be great.

Myles Helfand: Are there particular subsets of patients for whom you would really want a care provider to be taking those extra 60 seconds to ask about diet, ask about nutritional habits, and maybe push them in a better direction?

Jül Gerrior-Schofield: We have special populations, for sure. But my feeling is that everybody who is diagnosed with HIV should have a nutrition assessment. Obviously, that can come from a dietitian very thoroughly. But in general, everybody's getting weighed. Doctors are weighing patients. So we have a general idea of their body weight and their height; their BMI. That's number one, because we want to prevent them from going down this path of developing high lipids, obesity and other things. That's the basic person.

The second person, I would say -- and they're not in a particular order, but: those who come in with insulin resistance or pre-diabetes, which is more frequently these days. Hepatitis C is another special population. And I would definitely say people who are not getting access to food. A big question I would have is: How easy, or how difficult, is it for you to actually get a meal? Because approximately 35% of our cohort is defined as food insecure.

These are just basic questions. If they don't have access to food, then we can link them up with services -- social work and other things.

Take the example of someone who has cardiovascular risk. What does that mean? More frequently patients are developing these surrogate markers of cardiovascular disease in HIV. We know that, for example, high triglycerides and low HDL cholesterol, which is the good cholesterol, are the two most common lipid abnormalities in HIV.

Generally, providers are getting these lipid panels. So we would be able to see who's having high triglycerides, who's having low HDL; and that's a flag for a doctor to follow up with, "What are you eating?" and so on. As I said before, diet can play a strong role in trying to help reduce these factors. That's a very nutrition-specific thing that can be done.

I was speaking to a doctor earlier today who said, "Nutrition only comes to my mind when I see an obese person," because she's immediately thinking weight loss, and trying to help the patient's hypertension and things like that. She doesn't really think about when people are coming in underweight so much, because patients are generally asking for Ensure, which is this nutrition formula that is helpful if they're not able to get access to food. But I would rather try to educate people on the right kinds of food to eat, and rely less on these supplements, if we can afford to.

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